ATTACHMENT A
KCDDD Hearing Aide BILLING INVOICE
Agency Name: Children's Clinic "A" Address: 123 "B" ST
Seattle, WA 12345 Telephone: 123-456-7891 Describe # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Total Expenditures Hearing Aide Aero 211 AZ Earmolds Other Services Flat Fee Unit Price $895.00 $45.00 $500.00 Quantity 2 2 1 Total Amount $1,790.00 $90.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,380.00 Child's file must contain documentation that the items billed for were provided. Hearing Aid Reimbursements require preapproval via King County DDD's Extraordinary Expense procedure. Note
Digital BTE Hearing Aide III Biaural Monaural (rt & lt)
Month: Sept-2003 Client Name: Baby Jones
Audiologist: J.A. Smith
King County Vendor's Certificate
I hereby certify under penalty of perjury that the items and total listed herein are proper charges for materials, merchandise or services furnished to King County, and that all goods furnished and/or services rendered have been provided without discrimination because of age, sex, marital status, race, creed, color, national origin, handicap, religion, sexual orientation, or Vietnam era or disabled veterans status.
Prepared by: PRINT NAME & TITLE
Date:
SIGNATURE
Hearing Aid Invoice Example.xls
Invoice
10/29/2003
1:21 PM